Alec Logan has built up ties with the American University of Beirut. As part of the link up he has been hosting family medicine trainees in Scotland over the last 18 months. There has been much mutual learning and Reina has been kind enough to allow me to share her experiences that give a fascinating view of how others see us and our role in the NHS: –
10 lessons I learned from my journey in Scotland
1- The importance of a structured system
A major attribute to the primary care system in Scotland, without going into the intricate details of its structure itself, is the fact that it is structured! This is reflected by the geographical and administrative distribution of health centers all over Scotland; the 24 hour service coverage; and the enormous amount of people with different qualifications working relentlessly to attend to the different health needs of the population. The culmination of this structure, in my opinion, resides in the well-balanced delegation of responsibilities, which allows faster and more efficient response to medical needs.
If I were to represent the structure I would use the analogy with a tripod. Similar to this three legged frame, the Scottish health system maintains the stability of both individual and population health by relying on facilities, manpower and organization
Facilities of primary care system may not be always funded by the NHS but they do conform to certain standards set by the NHS. The setting of the clinic, the workflow and the documentation of medical information are essentially the same.
When it comes to individuals, a wide array of dedicated health workers work together in a team spirit (discussed further bellow). I have read in a recent article published in BMJ about the current NHS crisis in England, that it is this extra effort put by health care workers, driven by their own dedication and belief in the importance of their job, that have been driving NHS forward over the past half a century. And I have definitely witnessed that when I observed nurses, GPs, health visitors and others at work. They are all skilled, highly qualified and properly trained in their field of work. Most importantly, they are genuinely involved in making people’s life better. This momentum is definitely the highlight of primary care in Scotland.
As for the organization, one cannot but appreciate the policies, guidelines and strong system of audit and control. Practices are not alone; they are part of a larger framework. They are always evaluated, such as through QOF (quality and outcome framework). GPs also must submit yearly self-evaluations, known as appraisals. And the system is in constant change. I learned from one of the practice managers that the health system is going through a transition phase whereby practices are shifting away from the QOF towards “cluster working”, a peer-led and values/quality driven approach relying on professionalism of leading GPs.
I believe one would need years to understand how Scottish health system functions, but he only needs seconds to appreciate its importance and efficiency and the fact that it provides good quality of medical services to every single Scottish citizen.
2- Patient advocacy
Dr. Steve McCabe, a highly qualified GP who just celebrated his 20 years of practice in Portree, a town in the remote and heavenly island Isle of Skye, once told me: “I am not here to judge or doubt my patient; I believe what they tell me and do all my best to help”.
Dr. McCabe has been working for years to advocate for rural primary care. We were supposed to meet again in Edinburgh, where he was attending an RCGP meeting for that purpose, unfortunately our timetables did not allow for that meeting.
I learned from Steve that being a patient advocate is not limited to the doctor’s attitude towards his patient in the clinic, to him signing the legitimate 7 days sick leave, or to his decision about a plan of care. Advocacy is being pro-active about anything that can be of benefit for the patient, in other words, to be on his side. This can be in the form of an email the doctor sends to people in charge; a meeting with a higher counsel to change a particular law; an article published in BMJ or BJGP about difficulties in primary care; any possible way you can think of to voice your patients needs and concerns.
Advocacy is a way of approaching challenges and working on solutions. The most important part of advocacy being: empowering patients and engaging them in decision making. After all, we are treating the patient not the illness. If the patient feels in charge, he will do better. That being said, the format of the encounter shifts from being an interrogation or a checklist hidden behind the screen to an open-ended format. The first question is how do you feel, the second is how do you feel about it, the third is what do you think we can do to help you, the fourth is so what do you think of our treatment plan and so on. I barely heard a yes/no question.
The setting of the clinic as well defies the traditional hierarchal doctor-patient relationship. The doctor is facing the patient, but instead of being behind a desk, the chairs are juxtaposed in such a way that the desk is no longer a barrier. I discussed this with Dr. Alec Logan, the mind blowing, highly experienced GP and the skilled teacher, after I observed his clinic for hours. Dr. Logan makes very smart use of the space and particularly fancy this setting as it allows him to have a direct eye to eye contact with his patient, to use his emotional intelligence to pick up on the subtle clues of his patient disease and deliver clear and straight forward messages when it comes to treatment plans. Proof of success: patients leave the clinic happy, comply with treatment plans and know when to follow up.
3- Teamwork spirit
Primary care in Scotland is the hub of teamwork. Because of the complexity and diversity of the services provided, the manpower itself is varied and diversified. People who are involved in delivering health care come from different backgrounds: they include but are not limited to: doctors, community public health nurses like midwives and health visitors, community district nurses, community psychiatric nurses, practice nurses, physical and occupational therapists and pharmacists in addition to professionals like social workers. They form a network where each element is empowered by the other. The thread between those different elements is a respectful and timely communication.
A good example would be the health visitors who have a very interesting job. Health visitors are aligned with GPs; they follow up patients aged from 0 to 18 years allocated to them through midwives. Their role is to coordinate the care of their patients, form a partnership with the families, make sure that the environment is suitable for children to grow and assess their risk of vulnerability. Of course all evidence based. They start with an antenatal visit to the couple at 32 weeks, then they do their first visit at the age of 10-14 days, 6 weeks, 3-4months and 27 months and so on. In order to do that, they rely on well baby indicators: safe, healthy, achieving, nurtured, active, respected, responsible and included. They also stimulate the parents’ awareness of health needs through community groups like breast-feeding as well as providing them with reading materials… We visited, Sharon the health visitor and myself, a twin at their house. The mother, still on maternity leave, was at the house feeding the babies. Sharon first discussed with the mother her readiness to go back to work, the financial challenges, the birthday celebration plans, then swiftly moved to taking the height and weight of the babies, plotted them on their “red book” and made sure they were gaining proper weight and are up-to-date on their vaccines.
Sharon also uses interactive playing at her clinic to assess whether children are meeting their developmental milestones. By combining home visit and formal clinical assessment she is able to spot any developmental problems and act on them if needed. A week later, I attended a multidisciplinary meeting about a 4 year old girl who was noticed to have signs of neglect in the nursery. The meeting was attended by the 22 year old mother, the grandfather, Sharon, a representative from the nursery and a clinical psychologist. Sharon has been noticing a dysfunctional family dynamics and developmental delay in the child, she pushed for this meeting to address those problems. The meeting succeeded in putting the mother in action mode and driving her to take responsibility of her daughter, meanwhile Sharon was to keep her eagle eyes on the child to track changes. I was impressed by the dynamics of the discussion and workflow, but also by the cooperation between the different people involved, the respectful communication and the high level of engagement they all showed.
Examples of teamwork are endless. I went with one of the district nurses to change the dressing of a man in his fifties with lymphedema. We reached the house and found another nurse who started changing the dressing of the left leg. As the patient is quite obese, working on both extremities would be tedious and time consuming, so the nurses decided to split the work. Simple yet very efficient, avoided burn out and ultimately improved care.
Teamwork is how you describe practice nurses amazing work at the COPD clinic, complementing the management of a COPD exacerbation by a GP in the next door clinic. Teamwork is the synonym to the harmonious and complementary work between the district nurses giving John, the 70 year old diabetic, his morning Insulin dose, the pharmacist delivering to his door his statin and BP pills, the practice nurse drawing blood for his biannual Hba1C, the health board sending him an invitation for his bowel cancer screen, the occupational therapist making sure he will not trip with the carpets at home and the GP discussing his low mood. Not to forget the health visitor visiting his 3 year old granddaughter, and the social worker cooking meals and cleaning his house twice per week. This is a work of a team and a culmination of dedicated and genuine efforts.
4- Doctors are psychologists, they also do more when they do less
The general rule in primary care practice is reassurance. This is what I was told by one of the experienced GPs in Airdrie, Dr. Murray Lough.
Dr. Lough has been in primary care for 35 years, he has his own way to run the work. In his practice that serves around 4000 patients, patients leave a voice message, the GP calls them after a while and the encounter is essentially done over a phone call. If the doctor finds that the patient needs to be seen in the clinic, he would book him an appointment. Other than being very efficient, the whole system relies on the ability of the doctor to understand the psychology of his patient. Once alarming signs are ruled out, doctors focus on reassuring their patients, understanding their anxiety and in broader terms, their psychology. This same principle holds true during the face-to-face encounter, where the majority of the time is spent discussing the impact of illness on the patient and methods of coping. Soon after I met Dr Lough, he struck my mind with the following statement: physical exam in general practice has very small positive predictive value. He proved his theory right as I sat observing him for 2 days.
When it comes to pharmacotherapy, the general trend in all the practices I have been observing is removing medications rather than adding them. Doctors are also less keen for thorough investigations, rushed decisions or short term plans. Most of the complaints are observed rather than acted upon. Bottom line: after screening for alarming signs, reassurance is the key.
5- Guidelines and Generic medications, the answer to our dilemmas
Talking about this lesson is very dear to my heart, as I have been personally always puzzled by guidelines, and lost between the Americans, the British and the Canadians. Of course I still did not find the answer suitable to our own Lebanese setting, but I am convinced more than ever in the cost effectiveness and the epidemiological importance of guidelines in setting standards for medical practice.
It is not by coincidence or personal effort that the chest infection bugs are still sensitive to amoxicillin in Scotland. It is because of the prescribing system and guidelines. And the auditing of the prescription patterns as well. It is not by coincidence that blood pressure targets are met in diabetics, because all diabetics are prescribed the right ACEI. Guidelines are adjusted to the epidemiologic profile of patients, and those that apply to Scotland are different than those in England. And they are always updated.
Other than the guidelines, generic medications are the corner stone of the medical practice. Doctors do not have to memorize the name of 40 PPI, or the dozens of head to head studies comparing their effectiveness in treatment of GERD. They prescribe the best drug, with the better patient oriented outcomes, the better safety and cost effectiveness profile. If a new study suggests a new drug, it will be studied and implemented if it fits the Scottish population from a medical and economical point of view. It is all about creating a balance between health and economics, about fairness in the accessibility to medical care.
6- Nurses are hidden gems
There are tremendous responsibilities that can be done by nurses beyond the stereotypic functions we are used to. Most importantly, there is a huge improvement in the quality and efficiency of care when nurses are delegated more responsibilities.
After qualification, nurses can pursue many certification programs to become more skilled in delivering care in particular fields like heart failure management, diabetes, asthma, COPD and much more. I have sat with practice nurses for hours, I have seen them measuring peak flow rates for COPD patients, explaining how to properly use inhalers, adjusting medications and then informing GPs about changes. In one out of hours clinic (clinic that opened on a public holiday) the practice nurse working with Dr. Maxwell Inwood, a very hardworking and dedicated GP in Edinburgh, was doing almost the same work he was doing in his clinic. She saw patients with cough and sore throat, prescribed antibiotics for tonsillitis and adjusted pain medications for patients with sciatica.
I have no doubt that our nurses can assume similar roles. Being close to the patients, nurses can do much more besides blood pressure measurement and phlebotomy. From pap smear, to ear lavage, to vaccinations, to asthma and COPD clinics, nurses are efficient, knowledgeable, smart and meticulous. The question is: are we investing enough in their potentials?
7- Never let a patient go without documentation of safety netting
It is part of the encounter, like history taking and physical exam. Safety net as the term suggests, provides patients with enough options to make informed decisions once they step out of the doctor’s clinic. Besides educating about alarming signs, safety nets give them options to follow up.
Patients are informed about the likely duration of their symptoms and given information about how and when to re-consult if their symptoms persisted. In addition to explaining warning signs, they are told who to re-consult if a follow up appointment is needed. If the diagnosis is unclear, the uncertainty is discussed and the reason behind testing and investigations explained. The patient leaves the clinic feeling engaged, informed and most importantly safe.
GPs documentation of safety netting (they simply tick a box on their computer screen) once patient leaves the clinic is also a legal protection of the doctor’s practice in the setting of any surprising event occurring during the course of the illness.
8- Small details that make big differences
The following are small changes that can make significant impact:
- A urine dipstick in the clinic: Such a minor detail, yet it makes so much of difference. A 23 year old female with urinary symptoms, 1st To treat or not to treat? Answer: urine dipstick, takes 1 minute, easy to interpret and can be done in clinic. If positive WBC and LE, prescribe antibiotics and send urine for culture. Simple, easy and convincing way for patients to understand the rationale behind their treatment
- Take off the white coat: what is peculiar about being a GP is his image of a counselor, a friend and someone who is supposed to make life easy. This is the second dimension of our job that makes us the closest to our patients. The role of white coats, the iconic symbol of doctors and their way of recognition by patients, becomes very dismal especially when we do every effort to be close to them. As long as we are wearing the proper attire, the image of a family physician remains to have lots of respect and appreciation by patients who will not fear our white coats. Add to that the multitude of evidence on white coats being a major source of infection. Blood pressure measurement should become more accurate as well.
- Stay humble and low profile: I met GPs who have been in practice for more than 35 years, whose libraries span the entire wall of their living rooms, who know about the history of Levant more than myself, whose minds and intellect power discoveries and medical innovations, who stand behind legislations and laws protecting patient’s rights… yet who are the most humble and down to earth. They share what they know, they enjoy sharing and enriching other’s mind, stimulating new synapses and sparkling new ideas. They have the kindest attitude, treat you as a peer and embrace you like a mentor. Those people are role models and idols to look up to. Iona Heath is a great example. I met her for 60 minutes. 60 precious minutes. She left me with a thousand thought to ponder on. While doubting our overzealous health maintenance oriented practices, Iona introduced me to the world of health protection and the pitfalls of over-diagnosis. The most humble and kindest attitude… I couldn’t but dream of her spreading her words in our shaky Lebanese minds.
- Tea breaks: Having a tea break is a good idea for doctors to chat about patient cases. It also sparks interesting discussion and allows trainees and medical students to be part of queries on interesting cases. It is always good to break long stretches of work through short power breaks that reset the focus and at the same time benefit personal medical knowledge
- More house calls: I have always dreaded house calls and did my best to avoid the 2 house calls scheduled for the whole year. When I went to house calls in Scotland, I noticed how invaluable it is to observe how patients are doing in their own environment. House calls are life saving for patients who are physically unable to come to clinic. No heroic measures are needed, just screen for what can be catastrophic and manage with what you judge is needed. As long as they are not abused and are organized within a logical geographic boundary, house calls are a unique and interesting twist in a GP practice.
- Read Dr. Richard Lehman weekly reviews of medical journals in British Medical Journal: Introduced by the one and only Alec Logan, this is the fastest and most efficient way to stay up-to-date and catch up on the latest studies published in world’s leading medical journals. They save time, energy and put a smile on your face as you go through them.
9- No it is not perfect yet always under reconstruction
Like every other system in life, the national health system in Scotland is not perfect but it is in my humble opinion really close to being perfect. There are many pitfalls, lots of overworked nurses and GPs, unexplained long waiting time for a specialist consultation. There is also an obvious abuse of the free services by beneficiaries, reflected in a high percentage of missed appointments.
However the system is really dynamic, it is in constant change, driven by those pitfalls. It is always under research.
I met Dr. Andrea Williamson in an addiction center in Glasgow. She is a GP that has been working with addicts for years. She has also a Masters in Public health and a PhD. Dr. Williamson is now conducting a big study involving hundreds of thousands of patients to understand the reason behind missed appointments, this natural human behavior of abuse. The results will definitely change NHS approach in the future.
This idea of close observation, constant monitoring and audit allows most problems to be challenged, and most obstacles to be defeated. If a problem is spotted, it will be studied, addressed and resolved. This dynamicity keeps the work flowing and the system moving, always forward.
The best example on dynamicity is the move of the health system toward “cluster working”. The change from the out of date and bureaucratic QOF towards this new approach was driven by the observations of people from the profession itself. After realizing that QOF with its top down approach fosters linking achievement to payment, the directorate of population health improvement and the BMA Scottish General Practitioners Committee suggested a new model. Cluster working allows a peer led approach relying on GP’s professionalism and leadership skills to better address patients needs while maintaining quality and improvement framework. This gradual transition is smoothly planned through a four-stage approach allowing practices to organize themselves, set priorities and act on them. This whole idea makes me more eager to return to Scotland every year and track the change.
10- Scottish people are the most kind and hospitable
I was lucky to experience the Scottish culture at its best. Having lived in 3 different households, met dozens of new people I can confidently say the Scottish culture is a culture of acceptance and open mindedness. A culture of sharing, loving and reaching out to others. It is the greatest example on hospitality and generosity. The places I have been to were great; beautiful landscapes and breathtaking sceneries, yet the people make the places and Scots are incredibly kind. I can swear on that.
Thank you to Alec Logan and Murray Lough who are trying to devise a Lanark-shire School of primary care and to Bassem Saab, our Family medicine program Director at American University of Beirut, for making this opportunity possible.
Second Year Resident,
Department of Family Medicine,
American University of Beirut